Our babies are fragile, and learning how to take care of them is a delicate process, especially when they are newborns. Newborn babies sleep a lot in the first few months, and if they are not taken care of properly while they are sleeping, it can lead to plagiocephaly(skull flattening).

Introduction

Definition of plagiocephaly

Deformational plagiocephaly is the flattening of the skull due to forces being exerted on the skull.

When babies are born, their heads feel soft because the sutures of the skull have not fully closed yet. The deformation of the skull can occur either during pregnancy or after birth.

The flattening of the skull (plagiocephaly) that occurs after birth is the most common type of plagiocephaly, it is usually devlops after: prolonged supine sleeping (The baby is sleeping on their back for a long time), not enough time on their tummies, bottle propping ( when something else other than the baby or caregiver is holding the bottle), and car seats.¹

Overview of plagiocephaly

Types of plagiocephaly

Positional plagiocephaly

Positional plagiocephaly is the flattening of the skull that occurs from sleeping positions.

Positional plagiocephaly usually results in the flattening of the occipital bone of the skull (the posterior bone), which can be either one side of the occipital bone or both sides. 

In some cases, the flattening of the occipital bone is accompanied by some changes in the anterior parts of the skull.

The most common type of cranial (skull) asymmetry in healthy newborns is positional plagiocephaly, representing 5 to 48 % of asymmetry cases.²

Craniosynostosis

A human's normal skull consists of multiple bones that are fused by sutures. 

But when a baby is born, the bones in the skull are not fused yet, leaving room for the development of their brain.

Some babies are born with the bones in their skulls fused early or prematurely; this is called craniosynostosis.

Craniosynostosis causes the head shape to be altered. The premature fusion can be in one suture or several sutures in the skull.

This condition leads to intracranial hypertension and a delay in development.

People who have Crouzon syndrome or Apert syndrome suffer from craniosynostosis.²

Causes of plagiocephaly

External pressure on the skull

Deformational plagiocephaly or positional plagiocephaly is due to the external pressure of gravitational force acting on one spot of the soft skull bone of the baby over and over again, till the back of the skull gets flattened.

The noticeable increase in the positional plagiocephaly cases in newborns came after the “back to sleep” campaign by doctors advising caregivers to put babies in the supine position for sleeping to prevent sudden death infant syndrome (putting babies to sleep on their tummies or sides can lead to this syndrome) and indeed the incidence of this syndrome decreased by 40% but also led to the increase in the incidence of positional plagiocephaly due to the prolonged sleeping of the babies on their backs.

The baby’s preference for sleeping on their backs with their heads tilted to one side causes the baby to be vulnerable to the repetitive gravitational forces, which cause flattening of the skull.

The baby can prefer one side because of torticollis (neck muscles spasm causing the neck to turn to one side), ocular conditions, infant scoliosis (skeleton of the baby going sideways), or muscular imbalance on one side.²

Birth process

In the last month of pregnancy, the baby turns upside down to move the head towards the pelvis.

The foetus's head is large and soft, so it can be easily deformed; therefore, when it gets engaged in the pelvis too early, this can cause deformation of the baby’s head.

The early engagement of the baby’s head usually causes torticollis, which can cause plagiocephaly later on.³ 

Symptoms and diagnosis

Recognizing plagiocephaly

Diagnosis of plagiocephaly depends on thorough examination and taking enough history from the caregiver and the mother during pregnancy.

It is rare to find anterior deformation of the skull in deformational plagiocephaly, so it is usually misdiagnosed as craniosynostosis instead.

One of the things that helps to differentiate between plagiocephaly and craniosynostosis is the timeline of development.

Positional plagiocephaly develops from three to six months after birth, while craniosynostosis develops right after birth.

Some features can help differentiate positional plagiocephaly from other syndromes:

1. Occipital bone flattening 
2. Frontal bone flattening on the other side 
3. Forward displacement of the ear on the same side
4. Facial asymmetry in severe cases

Asymmetry of the head shape

In babies with deformational plagiocephaly, only one side of the head is affected, usually the forehead on the same side as the flattening.

In babies with posterior deformational plagiocephaly, their heads look wide, and the part of the skull above the ears is prominent.

Flattening of one side of the head

Babies who prefer to lie on one side or those who suffer from torticollis neck muscle spasms cause the babies to lie on a certain side, develop a unilateral flattening of the head.

Misalignment of ears and eyes

In severe cases, the child may suffer from asymmetrical eyes and ears.

The skull of a newborn is soft and has not fused yet, so the constant pressure on one side causes a forward displacement of the ear and forehead on the same side, causing both ears to misalign.

Diagnostic methods

Several devices can help craniofacial dysmorphology specialists diagnose plagiocephaly and differentiate it from craniosynostosis and other diseases and syndromes.

These devices include anthropometric callipers(a measuring tool that measures body parts), moulding devices, devices that use software analysis, and photography.⁴

Imaging techniques

Imaging techniques can also play an important role in the diagnosis, such as three-dimensional scanning and radiologic imaging.

Radiologic imaging is not usually needed in most cases of plagiocephaly 

Prevention strategies

Importance of alternating head positions

Once the child is diagnosed with positional plagiocephaly, there are lots of things that can be done to reverse the head flattening, like encouraging tummy time from time to time, changing the head position of the baby during sleep to prevent the development of a preference for a certain position.

Also, babies who suffer from torticollis or a short sternocleidomastoid muscle can be treated with the help of physiotherapy, and by educating the parent to constantly change the baby’s head position from side to side. Treatment of these two conditions can be done till the age of one. 

Use of supportive devices

Positioning pillows

The positioning of pillows or towels under their neck will help decrease the pressure on the side that got flattened.

Helmets and bands

Helmets and bands are considered corrective devices. Some researches indicate its importance; other researchers say that head flattening is self-correcting.

The idea of using a helmet to correct a head flattening is that it uses pressure on a certain part, allowing the other flat parts to reshape back into their normal position.

Summary

Deformational plagiocephaly is a condition of head flattening which occurs from some forces acting on the skull of a newborn.

There are two types of plagiocephaly: positional plagiocephaly, which occurs due to sleeping on the back for a long time, the baby has a preferred side to sleep on repeatedly or the use of car seats and bouncy seats.

The second type is craniosynostosis. In this type, an early fusion of the skull sutures occurs, causing the flattening of the back of the head. 

Some syndromes can cause plagiocephaly, like torticollis, which causes the neck muscles of the baby to spasm and tilt to one side repeatedly, causing flattening of the head on one side. A short sternocleidomastoid muscle can also cause unilateral plagiocephaly.

Parent education is important so they can reduce the time the baby spends on their backs and allow some tummy time, also to move the baby’s head during sleeping so it won't develop a preferred position, causing head flattening.